Tuesday, September 22, 2009

(If you think this post has ANYTHING to do with John Denver, you're in the wrong place. But it made a good title.)

I'm not taking sides in the health care debate, but I do want to clarify something.

I see people on the news screaming that they don't want "bureaucrats" between them and their doctor, and are afraid that's what government health care will bring.

WTF? THAT'S THE WAY IT IS NOW, PEOPLE!!! I hear my nurse Annie on the phone all day trying to get approval from non-government insurance companies for tests, medications, physical therapy, ANYTHING that I order.

Look at your insurance card. Doesn't it say things like "in-network" and "formulary"? Who the hell do you think came up with those? Not us docs. Dat be dem dere byoo-row-kratz!

Look back at some of my posts (like this, or this). I routinely have medications (both brand name and cheap generics) and tests refused by insurance companies. For an excellent commentary on this from the pharmacy side, this was written by FranticPharmacist.

So if you don't want bureaucrats between you and your doctor- TOO BAD. They've been there for years. THE ONLY PEOPLE WHO DON'T HAVE THIS PROBLEM ARE PAYING CASH FOR EVERYTHING!

In fact, for those of you who don't want the government running this, THEY ARE ACTUALLY ONE OF THE BETTER ONES TO WORK WITH! Just ask Annie. Medicare doesn't question the majority of my tests, or meds. Yes, they don't cover everything, nor should they, but they don't fight with me over stuff like MRI's on stroke patients. Uncle Sam (unlike BCBS, Aetna, Cigna, United, Humana, and many others) tends to leave these things to the doctor's discretion. Annie prefers Medicare patients for this very reason - they make her life easier.

So what happens to you the way it works NOW, with your non-government insurance?

You come to me for some neurological issue, which requires further work-up. So I order, say, an MRI and MRA of your head.

Annie gets the order, and calls Bozo Insurance, Inc. (BII) to schedule it. BII refuses, saying they want more information. So they fax us a 5 page "pre-auth" form, which Annie spends 20 minutes filling out and faxes back. Then they say the form wasn't enough, and they also want copies of your office notes, so we send those, too (yup, when you joined BII you agreed that they can read your medical records).

So a few days go by. BII will claim they never got our fax. Or that we filled the form out wrong. Or that they don't cover Capricorns when the moon is in Pisces. And we don't know this until Annie calls back after a few days, because they're hoping we forgot about it.Eventually they'll deny the whole thing, on the grounds that you don't meet criteria for an MRI and MRA. This decision is usually made by a non-medically trained person with a minimum of a GED. They do this because they want to see just how badly I want the test.

So they tell me I can appeal this via "peer-to-peer" review. Which means I need to personally call their "physician reviewer" to argue with them as to why I want the study.

So, during my insanely busy day at the office I have to call them. I'm promptly put on hold for 10 minutes, before finally reaching the reviewer. This person is a doctor- but NOT necessarily in my specialty. In fact, it's usually something like a retired dermatologist, who hasn't done neurology since medical school in 1938. Or an OB/GYN who hated his job, and is doing this now instead. Or some doctor who immigrated from Lower Swazbodiaczk and can't get a U.S. medical license (but your insurance company hired him to decide what medical care you need). But it's almost NEVER someone actually in my field, who might understand why I want the study.

So after telling your life history to Dr. Denial, one of 2 things will happen. They'll deny both studies, and want you to try medication or physical therapy or psychotherapy or holistic reflexology or whatever, and if you fail that THEN I can try to resubmit a request for the test. OR they will flip a coin and say they will cover the MRI, but not the MRA. Or vice-versa. They'll say that if the first test is fine, THEN I can start over trying to get the other covered. Maybe.

And many of these companies actually pay these "reviewers" bonuses based on HOW MUCH MONEY THEY SAVED THE COMPANY BY DENYING TESTS.

This can at times become comical. One of my patients is a doc who works part-time as one of these insurance company "physician peer reviewers". And when he needed an MRI, guess what? HIS OWN COMPANY DENIED IT! He paid out of pocket for it (and yes, it was abnormal).

So how did I get on this tangent? Because yesterday I was walking by Annie's office, and heard her losing it over the speaker phone. And, as always, she was totally awesome.

Annie: "I'm calling because you people denied an MRI on a stroke patient?"

Pinhead: "Before we discuss this, I have to inform you that this is a recorded line."Annie: "Oh, good, hopefully someone will actually be listening to me then. Thus far it hasn't happened."

Pinhead: "Let me look up the tracking number... Okay. I have to inform you that we are unable to approve this study. Your doctor will need to make a peer-to-peer call."

Annie: "Oh, now THAT's a surprise."

Pinhead: "What do you mean?"

Annie: "Is this line really being recorded?"

Pinhead: "Yes. It's to improve customer satisfaction."

Annie: "Oh, goody, because I'm sure not satisfied, and neither is the doctor, or the patient. Your company, and whoever is listening, never approves anything. In fact I can say that 100% of the time you require peer-to-peer review."

Pinhead: "We do this to save our customers money on unnecessary testing."

Annie: "Think about it. You have benefits and a salary, right? I mean you're not doing this as a volunteer job, are you?"

Pinhead: "No, but I..."

Annie: "So wouldn't your company save money by firing you and instead getting a computer that automatically denies every damn test and sends a fax telling us to call for a peer-to-peer review? Then we can just let the doctors talk directly to each other from the beginning, which is what you bozos want anyway. Think of the money saved by cutting all of your jobs."

Pinhead: "Oh, but you can't mean that?"

Annie: "Oh but I do mean that. And I'm glad we're being recorded. Let's consider the current situation. You are basically a worthless automaton. A computer could do your job for far less. And at this point you've incurred the wrath of all the medical professionals in the country as well as the patients. You and all of your superiors ought to be out of a job due to your blatant inefficiency. And don't think we don't save your denial forms, and your names, and document it all in the chart."

Pinhead: "I..."

Annie: "Nothing personal you understand, just a suggestion. I'll have my doctor call your doctor. Have a nice day".

Pinhead: "No, wait! I..."

Annie hung up.

So bottom line here: if you don't think bureaucrats are currently between you and your doctor- THEY ARE! GET REAL! IT'S BEEN THAT WAY FOR THE LAST 10 YEARS OR MORE!

68 comments:

As a person with a chronic condition who is paying out of my nose for the best insurance plan - a PPO - it's always appreciated when doctors and nurses fight for us. I'm not denied nearly as often as I used to be, but I still have to fight.

Sometimes I have to fight for insulin. I'm a type 1 diabetic. Have been for 20 years, since I was 12. Every year or so I have to prove I need insulin. Riddle me that one.

people will believe whatever the TV tells them to believe. I'm not saying government health care is the end-all, be-all, but the private providers are businesses first and foremost. They are all about making money and as such are going to sacrifice and cut corners wherever they can. I'm not being cynical here; they can provide service if they go under either. However, a fundamental issue centers around executive bonuses tied to financial performance. They will pay lip-service to customer satisfaction, but it all comes down to the bottom line.

Having been a corporate executive, I've seen these types of decisions made time and again. It's sad. Then the government is compelled to step in because the private sector cannot regulate themselves. With you it's insurance companies; with me it was mortgage brokers and appraisers.

Yeah, it's frustrating, but it's better to talk to a peer revieweur than not have the MRI available to use AT ALL (at least for a few months) or to have to change a law to get your medication. My friend in Norway's mom who had trigeminal neuralgia had to wait 5 years just to talk to a neurosurgeon after a "5 year trial" of tegretol didn't relieve the symptoms, so..........................

I have tried to reason with my elderly parents who believe all the nonsense being spouted about death squads and government meddling... I am going to send them this link - and hopefully they will read it. They tend to believe anything and everything a doctor says, even a grumpy one (but that's a post for me to write!)

Well, with costs out of control, doesn't it make sense to try to keep costs down on the most expensive drugs in their class and the most expensive imaging?

I wish some peer reviewer would just park in my ER and tell Dr. Controlfreak and Big Work-Up 3x/shift that every knee pain doesn't need an MRI and every 20 y/o with a headache doesn't need one either so your stroke patients can get an MRI w/o question. Every 18 y/o with pleurisy doesn't need a CT scan to rule out PE. Also, NovoSeven at 8K/pop on a patient actively herniating with GCS of 3 x 2 doses, maybe let's peer review that sh*t.

It's people like Drs. Controlfreak and Big Work-Up that are making your life difficult, not the insurance companies per se. If MDs were testing appropriately for the most part, you wouldn't have to have a microscope up your rectum qMRI.

Funny you posted this less than 24 hours after I had to call my seven-year old son's pediatrician to beg them for a letter of medical necessity to send to our dental carrier. Because the fine print states that once a child turns 7, they are no longer eligible to go to the pediatric dentist; they must instead go to a regular doctor. Seeing how my son has autism, and I researched the entire city for a pediatric dentist that welcomes special needs children... ARRRGH I am already getting worked up again.

Our peds office is awesome, however. They gladly wrote the letter for me and did not charge one cent for it. I was surprised at this and told them that my GP charged 10-20 dollars for paperwork like this! Too bad that bill couldn't go right to the insurance company...

Awesome post! This should be required reading for every patient who complains that their doc doesn't spend enough time talking to them. No other health system in the world tolerates this type of waste of time and energy. People who think that private, for-profit insurance is the only possible solution to our health care problems need to wake up.

I'm sorry, but if you think Medicare is one of the better to work with I'd like you to spend a day in a pharmacy. Medicare is simply awful to pharmacies with their "let's pay them less than it cost them to buy the drug!" policy. Ugh.

I hate insurance companies. I also have type I diabetes, an it is a pain in the ass to deal with them. However, we are really stuck between a rock and a hard place. Many people believe that the government should pay for everybody to go see Dr. Grumpy. (Remember, it's not free- because Dr. Grumpy has to eat, pay his secretaries, etc). So now, there is at least a nine month waiting list because everybody wants to get an MRI.

Let's put it this way. A summer blockbuster comes out. You go to see it, only the damn thing is sold out. There is a line to buy tickets. Doesn't matter how free you make it, everyone wants to see it. But you can't. Here's a thought- maybe some of the $700 billion we gave to Wall street could go towards health care.

Your defense of the insurance companies doesn't make sense. If the docs you work with have lousy clinical judgement, they are the ones who should be hassled. How does making sweet, innocent Dr. Grumpy's life miserable solve the problem?

Health care reform is needed, but we won't find the perfect solution. People try to demonize the different groups -- insurance, pharmaceuticals, government, lawyers, hospitals, etc. But, what everyone needs to consider is that real people work in each of these areas. None are evil, none are perfect, & room for improvement in all.

Ironically, I just posted my experience in trying to avoid a stat MRI on the weekend at a small hospital. We all get caught up in our routines & policies, & forget how to think.

Anon: Since many doctors do order inappropriate tests and there would otherwise be no other way to prevent this (there is no disincentive for a physician to not order piles of tests in a lawsuit-rich environment), the insurance companies have to try to make their product affordable to you and I by screening for stupid tests. Not great, but better than, as I said, not being able to do an MRI at all for months or years as is the case due to rationing by lack of access to technology (or a technology shortage) as is the case in most government-controlled situations.

I agree with your statements on beaurocracy and I'm all for Universal Health Care....but Medicare is nearly bankrupt, which clearly would be the case with any system run by the government eventually. Especially since so many more people will be enrolled in a gov. system. This will lead to more rationing over time. Get ready!

But isn't original point that your docs are still ordering stupid tests, so what is that insurance hassle accomplishing?

I liken it a parent with two children and, when one misbehaves, the parent spanks the other one. You're saying the misdirected spanking is the fault of the brat; I'm saying it's the fault of the stupid parent.

"the case in most government-controlled situations"

Certainly not with Medicare or Medicaid. And not the situation in Australia, France, Italy, Germany (I've worked in all those countries). You'll probably bring up Canada, but that's an outlier (as we are) among the world's health care systems.

Not great, but better than, as I said, not being able to do an MRI at all for months or years as is the case due to rationing by lack of access to technology (or a technology shortage) as is the case in most government-controlled situations.

Name a few.

Funny, it took 5 years here in the U.S. for me to get an MRI (or any testing at all) to diagnose my MS, what with only having university-issued student insurance when I first stopped being able to feel my right foot. So the made-up worst case scenario would still cut waiting times for the uninsured and underinsured!

Poor Dr. Grumpy is busting a gut to put more bucks in the pockets of the starving radiologists. He doesn't benefit financially from doing the test, and he doesn't share in the savings when the test isn't done. Many docs in his situation have lost all interest in working for free to help the insurance companies increase profits.

If insurers really want to save money on imaging studies, they could:

1. cut reimbursement to overhead plus five bucks (like office visits from primary care docs); some of this financial pressure would then be transferred to the manufacturers of the magnets, who currently operate without any financial constraints; and

2. make the doc who is doing the imaging (the one who bills for it), be they radiologist, orthopod, whatever, be the one who goes through the pre-cert process.

Liz: Medicare is going bankrupt because of inadequate funding. If Medicare funding had increased at the same rate as private insuance premiums over the past 30 years, there would be an enormous surplus.

Hey thanks for the shout-out, Dr. G. All we can do is try to educate people what it's like in the real world. Keep the debate civil and INFORMED, is all I ask.Tell Annie to hang in there. In our clinic we have a nurse who we call the Prior Auth Queen, and we all bow down before her...!!

Most primary care docs I know no longer order MRIs or CTs. Instead, they refer the patient to a specialist, where they get an expensive consultation, expensive further testing, and the indicated imaging study.

This allows the primary cares and their staff to spend their time caring for sick patients, and gives them the satisfaction of knowing that the insurer will be forking out big bucks because of their perverse bureaucracy.

Years ago my son was injured during a football game. I started to worry when, after many minutes, he still couldnt catch his breath and was cold and clammy - complained about rib pain. The doc from the other team came over and agreed with me he needed to be seen. Of course, this was an evening game and before everyone, including the players, had cell phones. No way to get pre-authorization until I actually got to the ER with him. Of coures it was denied .... but one nicely politely written letter and one phone call demanding to know what medical training that would supercede an MD's training the person who denied the claim had...they paid the bill.

I'm pretty sure I don't have to deal with the bureaucracy and I don't have to pay cash for everything.

I have a PPO and an HSA. I have a high deductible and a slightly higher out of pocket maximum.

I get to do whatever I want and I pay everything until I reach my deductible. It sill comes out way less than paying for an HMO that covers everything.

Once I hit my deductible, I pay a percentage.

Once I hit my out of pocket maximum, I pay nothing.

It is my understanding at all stages that I get to do whatever I want (within some reasonable limits I'm sure).

I think the bureaucracy argument is used primarily because it sounds better than saying we don't want to pay for other people's health care. As long as I get to keep my PPO/HSA, I don't really care what happens to anyone else. But I definately don't want to expand tax payer funded health care. I don't buy into the idea that health care is a right.

I work in the insurance industry. My department is involved in radiology utilization management. I'm not clinical, so I'm not involved in the decision making, but in the clerical/admin end of things.

It's not my dream job, or my final empoyer, but neither do I feel guilty about it. Yes, Big Insurance has it's eye on the bottom line, but radiology utilization management is not without medical and financial benefit to the patient.

For every boneheaded decision that gets over-turned on appeal, I see at least two or three cases where the MD hasn't even bothered to do x-rays, ultrasounds, or something else basic that would provide the same information. It's not "holistic reflexology" that gets recommended when appropriate, but basic physical therapy.

If nothing else, I want Dr. Grumpy to know, for the record, that it is SO VERY ILLEGAL for non-medical people to make that type of decision. I can't speak for everywhere, but it doesn't happen where I work. Not only that, but we don't employ doctors from "Lower Swazbodiaczk" who can't get US medical degrees. Our docs have to be licensed in every state where they review patients, and keep current. That's actually the law.

I'm sorry. Again, I support healthcare reform, I support the public options, I have no delusions about the true motives of Big Insurance. But this kind of misinformation pisses me off. On my good days, I feel like my department is helping our insured make the best of a bad situation.

Right on! Bravo, Annie! I think if we in health care had lost our tempers some time ago, we might be at the point where a strategy of 'simply tightening up the process' might be an acceptable and viable alternative (as proposed by those that oppose major reforms such as single-payer, public option, or universal care.)

Nurse K forgets Dr. G's bottom line; it's been this way (and has been getting more and more out of hand) for years.

A long, long time ago when I was in pharmacy school we debated HMOs, PPOs, DRGs and Medicare, formularies, my physician's explanation that the initials after her name on her sign indicated she charged the usual and customary fees. In the 80's we discussed how it wasn't such a bad idea for pharmacist involvement in establishing certain therapeutic standards, with the counter-argument that 'just who did pharmacists think they were in questioning physicians' prescribing practices'.

Not too much later, on a VA residency, we were out of work for a few weeks in the mail-out pharmacy because there was no Federal funding for filling prescriptions. Five years later at non-profit hospital, our pharmacy dept. was to be sold to a less expensive managing company because the hospital had come up with this as an emergency alternative when state Medicaid funding was cut.

With drug companies lobbying Congress for special price deals on Medicare and Medicaid contracts, and negotiations for the reimbursement with private insurers, as well as payment to other health care providers, it's no wonder employers had to readjust insurance contracts resulting in increased premiums, (and, that only applies to those that could get insurance through their work.) And, if there's any indication that this got under the radar, just how familiar are the blog-readers with the fact that Pfizer was just fined $$ billions by the FDA for unfair trade practices in marketing Bextra over Vioxx which was going to be pulled?

Costs of visits and fees increase every time insurers (and others) come out with increased premiums and decreased coverage, all based on what folks 'handling' payment and charges (essentially the insurers) dictate, whether for patients depending on Medicare, Medicaid, or private insurance. Well, several small locally-owned retail drugstores in town went under, not just because Wal-mart came to town.

That's how I can understand it in my mind; may not be necessarily the extent, i.e. may be simplistic view, but in any case, it seems that that the people with the power are those handling finances, and they are as culpable in greed in ways beyond my imagination as those in the banking industry that nearly toppled the world. (May be a slight exaggeration, but seems to fit the tales of excess.)

WE in health care know a few things; no one has been seeing insurance fees decrease, health care hasn't really improved all that much across the board, there a certain number of citizens out here disenfranchised due to issues really out of their control that can lead to less freedom of life, liberty and the pursuit of happiness than other citizens, and there aren't a lot of us real happy about the present state of health and care.

Anon from the insurance company proves the point I tried to make. We love to blame the anonymous enemy but forget that real people are involved. I highly doubt that there is a single person who works for an insurance company and goes to work thinking, "hmmm...how can I screw someone out of health care today?" We have patients who think that nurses are lazy (oh boy, spend a day with me) and doctors are incompetent. Most people think that government employees are unethical & scamming the system. Point is that there are good & bad people in all careers, at all levels.

We need to quit with the angry town hall meetings and insist that our government sits down to find a solution. I guarantee that whatever they come up with won't be perfect, and we'll all wish it was different, but nothing in life is perfect.

This post deserves a measured response. I'm British, Scottish to be precise, and exactly one year older than the british National Health Service, which one might consider was the one enduring achievement of the UK's post war socialist government, until the present lor started to ruin it in spades. My father trained as a physician in Glasgow in the 1930's at the end of the depression. One of his anecdotes was that advanced pathology was much commoner in women and children than men, most of whom had some sort of health care cover through employment. (For a fictional account of a similar situation in the Welsh mining areas read "The Citadel" by A J Cronin). Both my father and my wife worked/work in infectious disease treatment & epidemiology after post grad training in Public Health medicine. So all my life i have had hammered into me the need for basic healthcare, free at the time of use, as being as important a part of civilised life as clean water and efficient sewerage. This begs the question what is basic health care. I have always thought that it is ideally the healthcare needed to maintain a person in health, health being defined by the WHO as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". because the WHO definition could be stretched to include cosmetic surgery counselling and high colonic lavage, I'll settle for basic health care being that needed to produce the absence of disease and infirmity.

Enoch Powell was the first British politician to articulate the self evident truth that the demand for health care is infinite but resources are finite.

The real consequence of the realisation that resource are limited but demand is limitless has been the rise of the health economist. Their eructions often look at the bang per buck of health care interventions. And the result is that in the UK expensive interventions, which don't meet some arbitrary criteria for cost:benefit ratio are simply not available. OK. So suppose you can pay for the particular treatment yourself. Fine except you will then find that the NHS may not pay for any of your treatment. Its All or Nothing in most cases. And most people who carry top up medical insurance in the UK will find that whilst it may cover their hip replacement, their MRI in weeks rather than months, getting their colonoscopy done by a gastro-enterologist rather than a nurse or even having their prolactinoma winkled out, it won't cover the total cost of a very expensive long term treatment package.

So a single funding provider has a lot of power to ration care.

The mind set of most physicians is to do everything they can for individual patients. This is in the spirit of the original Hippocratic oath - "I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone". The modern trend in medical ethics in Europe is to teach the need for a "just and equitable" distribution of resources. In other words, the physician has to bear in mind the effect on others when massive resources are proposed to be devoted to one patient.

Even taking that into account, there is always going be conflict between the individual physician, who will want the best and most appropriate treatment for her patient and the paying authority. The US system, as described by Ibee Grumpy and many others, seems to be rationing by using using semi-educated call centre workers to set hurdles which the patient and his doctor have to negotiate in order to get the appropriate care. In England, its the same, but different. Reading what I can about the proposals to reform it, I am not at all convinced that their implementation will produce a system that gives a better deal for patients and enables health professionals to spend more time with their patients than with their paperwork. But it must be hell at times trying to doctor and nurse within your present system.

Nurse K and anyone else who opposes Universal Health Care on the grounds that in a socialised health care system there are waiting lists forgets one thing: when the national system is reasonably good and nearly universal, private insurers have to become very competitive in order to be attractive to the people willing to pay in order to skip the waiting list.

I'm Spanish. My husband pays about 900 euros a year for the best private healthcare you can imagine. No co-pay. It's one of the most expensive insurance companies in the country, too.

A fantastic entry that really drives home how improperly informed many people are; especially the loudest ones.

The plan currently in debate might not be the best alternative, but it sure as heck burns my bacon to hear people swat it down and then provide no meaningful alternative and say the system is fine as it is.

If you don't think people have the basic right to be healthy and not become deeply indebted (and therefor have their quality of life massively reduced through no fault of their own) because they got bad genes, or just had an unlucky accident, well. Maybe this whole equality/freedom/America thing isn't for you.

At the end of the day, though, I thank you guys for doing what you do. Three cheers for Annie especially!

"A fantastic entry that really drives home how improperly informed many people are; especially the loudest ones.

The plan currently in debate might not be the best alternative, but it sure as heck burns my bacon to hear people swat it down and then provide no meaningful alternative and say the system is fine as it is.

If you don't think people have the basic right to be healthy and not become deeply indebted (and therefor have their quality of life massively reduced through no fault of their own) because they got bad genes, or just had an unlucky accident, well. Maybe this whole equality/freedom/America thing isn't for you.

At the end of the day, though, I thank you guys for doing what you do. Three cheers for Annie especially!"

1. I do try to elect politicians who will be fiscally responsible....my fellow citizens don't always vote my way (and too bad, too!)....

2. I'm a hospice nurse, and I understand that 'death panels' is hyperbole. I am completely behind not aggressively treating those who will not benefit from it.

We should really just get government out of it. I don't want some gubmint flunky deciding rationing decisions (although I'm not necessarily against it, the problem is WHO is going to be deciding these things!)....

I will never believe that government should have this level of interference in our lives.

Again, I say I would welcome a universal system that works....I just don't believe that the Government can ever sustainably do it. Not ever.

"Well, with costs out of control, doesn't it make sense to try to keep costs down on the most expensive drugs in their class and the most expensive imaging?"

YES...the question is not whether you do it, but HOW you do it.

"I wish some peer reviewer would just park in my ER and tell Dr. Controlfreak and Big Work-Up 3x/shift that every knee pain doesn't need an MRI and every 20 y/o with a headache doesn't need one either so your stroke patients can get an MRI w/o question. Every 18 y/o with pleurisy doesn't need a CT scan to rule out PE. Also, NovoSeven at 8K/pop on a patient actively herniating with GCS of 3 x 2 doses, maybe let's peer review that sh*t."

OK...Obviously you don't have people telling you on a daily basis that they are gonna SUE you if you don't do X, Y and Z. Let's see...I'm $200K+ in educational debt. I have a family to support and know that an attorney that's hungry enough, unethical enough and sleezy enough, I could cause me to go broke. It may be a 1 in 10,000 chance, but here's the decision - order the test that you don't pay for or roll the dice. Thanks to the corpo-go to guys we have in Congress, the ins company can't be sued for saying no, but I can. I say bring on universal health care, develop best practices and use it as benchmark to measure whether the care delivered was appropriate or not. Health reform without tort reform is useless.

Dr Controlfreak and Big Work-Up are responding to the greedy, morally bankrupt lawyers, insurance companies and Congress looking out for themselves at the expense of health care providers, patients and the public at large.

amen and amen!!! my ins,. co. allowed me to go through all the clearances for gastric bypass surgery. the day of surgery i show up at the hospital, only to find out my surgery was denied. my bmi was 42 and at 5'3", i weighed 250lbs. i have many health issues and take many meds. the surgery as you well know would've eliminated alot of these issues and meds. ultimately saving alot of money at the end of the day. the surgeon and hospital did everything to talk to the moron dr., who didn't know me from atom. his reasoniing was i had lost 42lbs. several yrs ago. I was in my early 30's! I tried many weight loss programs, but at 45,this wasn't happening. by the way, these idiots spent $23,000.00, not including my meds. i took 12 different meds then. that was 7/2005. i was diagnosed with type 2 diabetes in 5/07. this year by may, i have been dignosed with diabetic neuropathy and mild arteriosceloris. i have been hospitalized at least 1-2x each year with asthma, diabetic and heart issues. i now take 17 meds. each day. i was hospitalized again in august. it's nice to know this expert dr. has a hand in deciding the length of my life. people are worried about "death panels"? the insurance companies have had them for years. i know this comment is long-winded, but this is shirley's song.

Actually, there was a docu-dramaabout 7ish years ago about thisvery thing. It was about a whistle-blower doctor who went towork for an insurance company. Sheblew the whistle and became anactivist. We can see that thingshaven't changed since then, and have only gotten worse! It seemsthat knoweledge has bred apathy!

I laughed (while shaking my head) about all the dang forms, filling them out, being denied, and having to resubmit them in quadruplicate for further disapproval, because that's what I put up with as a legal assistant in an insurance defense law firm. I was a government employee for 9 years, and it NEVER got that ridiculous!

Insurance companies even get away with scrutinizing bills from their attorneys and paying less for legal representation than everyone else. I'm not saying this hurts lawyers much, if at all, as it's obvious the ones who can put up with insurance companies' bureaucracy can make a sh'load of money.

Anon 7:34 pm's comments reminded me that doctors also have outrageous premiums to pay for malpractice insurance! It just never ends! btw, the attorneys I knew who no longer work in the insurance defense are now representing plaintiffs in personal injury or medical malpractice because that's where the REAL money is. I could go on, but I've already added more than 2 cents here.

We need more critically thinking nurses like Annie. She's too awesome for words!

I am very close to someone in the insurance industry - a physician who occasionally does reviews/approvals/denials. Through this person I have now seen both sides to the debate. One the one side is the unfortunate need to be profitable as a company (after all we are capitalists), on the other, the need to serve the individual. These are not easy to reconcile. My friend does lots of research out of his original field to better understand the requests of physicians and does not summarily deny cases. Often, there is no way to properly get an idea of what the situation is without directly calling the MD. Just "indication: headache" for MRI, MRA, MRV, PET scan, CT angio, etc is simply not enough to approve such expensive tests. That said, the insurance industry has to realise that health care is not like any other industry as there is an ethical need for it. You can't just treat it like some other commodity. Clearly, getting rid of pre-exhisting conditions has to happen to maintain fairness. Second, healthy young people must be forced to buy insurance - either privately or debatably via some public, basic, low cost option taken out in pretax dollars. This would offset the expense the insurance industry would incur by not jacking the rates to people with diabetes. Also, I think we are headed to a two tier system. A basic public option where there are out of pocket costs for most things (but affordable costs like the poster from South Korea describes), and also private supplementary insurance where the out of pocket costs are mostly in the premiums. We shall see what happens and if in fact the government remains as incompetent as we all think it is.

I run the pharmacy at one of our cancer center's satelite locations and I have to say that I spend more time verifying insurance authorizations than anything else, which is a damn shame, as it leaves me with substantailly less time to check for interactions/allergys/compatibility/etc. The thing that really gets to me is that the ones who are actually are paying for insurance always get the short end of the stick. They must fail certain lines of treatment before getting approval for the plan originally intended. Prior auth for this and that and everything in between (yes, they will go out of their way to not respond to a prior auth for a drug until AFTER the 3 day window to give the drug has passed) Some will only pay a percentage of the treatment. Who can even afford to pay 20% of chemo cost? These drugs are not cheap… no shame, these companies have and it makes me absolutly sick. No one should be forced to go bankrupt because they have cancer. Have you really gained anything when you overcome a disease, but are left with no house, no money, no nothing??

Now, take the patient on Medicaid, who basically has no out of pocket expense. Medicaid was originally a wonderful idea, in my opinion, but now has become out of control and heavily abused. We had a Medicaid patient recently and the doctor wanted to change his treatment. He asked me if this would be authorized, so I called up the billing dept and started asking about approval of this treatment. The billing girl basically cut me off stating, “does not matter, he is Medicaid, doctor can prescribe whatever he wants, it will be covered”

Wait. Really? So the patient who works hard and goes out of their way to make sure they have insurance coverage gets less than ideal, substandard care, but the one who contributes nothing gets everything under the sun?? How does this make sense?? Isn’t it the working class who pays taxes to support these government funded programs?? This is strictly only what I have seen from a pharmacological point of view, not sure if it is different with tests, doctors visits, etc, but it seems absolutly crazy. Why should I continue to pay for insurance (and payroll taxes for that matter!) when Mr. Deadbeat with no job or desire to contribute to society is receiving top of the line care for free?? (This obviously does not pertain to individuals who can rightfully justify usage of these kind of assistance programs)

I have an extremely open mind regarding attempts at solving the healthcare issues we are facing today. If a cartain attempt fails, at least we know what does not work and can improve on that. To me, the end result will be more effective than continuing to do nothing at all.

Ohh, this was all kinds of awesome, I salute you sir! And Annie, I am in awe of a most excellent & wry turn of the tables on the bozo insurance minion! "You are basically a worthless automaton"... ROTFL! You've made my day/week/month, a bow to you and your wit!

OK, what this post brilliantly demonstrates is an example although we (the patients) buy health insurance because most of us can't possibly afford any kind of serious illness, the fact of the matter is that the insurance company is acting in its own best interest, not in ours. There is no way that can work, no matter how many ombudsmen, competent peer reviewers, whistleblowers, etc. the world manages to come up with. The flip side is that as a patient, I want the best care, regardless of price--too frequently, having insurance means I don't necessarily know what the price _is_ because I dont have to pay it.

Basically, any purchasing decision (and choosing what tests and meds to use is fundamentally a purchasing decision) involves tradeoffs--price vs. usefulness. The tradeoffs I'd make if I were paying myself are not the same as the ones I make given that I have insurance. And the tradeoffs the insurance company chooses are not the same as the ones I would choose in any case.

If the American health system is so messed up then leave! I live in Australia, the government run the health system, if I need an MRI or any other test I get it. There might be a couple of days wait for non-urgent cases, but in the main its simple, If a doctors says you need it, you get it!!they are the experts! What does it cost? Well, just over 1% of our taxable income is the Medicare levy, and this entitles us to 85% of our doctors bill paid by Medicare, and for a vast majority NO ADDITIONAL COSTS for tests. There are waiting lists for elective surgeries but so what. I've had two kids in hospital and two other hospital stays and have never received any bills for these stays. Any medication prescribed costs a maximum of just over $AU20. I think the Australian Government has one of the best healthcare systems in the world.

That we in the US don't think of healthcare as a right for all is just a sad indictment of our current capitalistic society. Anything to make the most money possible on the backs of those who cannot adequately advocate for themselves.

@ Double Standard: WOW, that was harsh. So the unfortunate lower class that cannot afford any type of insurance on their own, many times through no fault of their own, including losing their job to the recession, car accidents, being injured at work, or having congenital defects, deserves to be treated as less than you? I'm guessing you're not a Christian and have never known any hardship in your life.

@ Anon 5:49: Don't I wish that I could leave. I would gladly move to Australia, Canada, the UK or any other country in the world where people believe that healthcare is a RIGHT and not a PRIVILEGE of the rich in order to get universal health care. Unfortunately it's not as easy as that.

Three cheers for Annie!! And as to your main point, hear hear. When I hear people talking about losing their "freedom of choice," I suppose they have never had crappy HMO insurance--or gone without entirely.

Just to clarify a point on the Australian system - if your prescribed drug is on the Pharmaceutical Benefit Scheme, the maximum co-pay is capped. If it's not, then it's more. I know we pay $35(ish) AUD for Nexium, for example.

That being said, as an American expat living in Australia and a nurse, I much prefer the Aussie system. It's not perfect but it's a far sight better than the US. And Annie totally rocks!

*MJH, CPhT said... I'm sorry, but if you think Medicare is one of the better to work with I'd like you to spend a day in a pharmacy. Medicare is simply awful to pharmacies with their "let's pay them less than it cost them to buy the drug!" policy. Ugh.*

Also a CPhT here, Dr. Grumpy's staff gets to deal with Medicare... We in the Pharmacy usually don't. Remember when dealing with Part D (which unless you're dealing with DME its what you're billing) it is NOT government run. its still Aenta, Medco, WHI, and the like. And government plans like DoD Tricare aren't allowed to negotiate for better prices because of the Drug Companies Lobby. The government plans actually have better reimbursement rates than the 3rd parties, and they're faster about it too.

Yes, the health care industry is a mess, whether the government is running it, or the insurance companies are. How about this - if people took responsibility for their own health, we wouldn't be having this discussion. It's the crux of this biscuit. If the public simply practiced a healthy lifestyle, good nutrition, and adequate exercise, obesity wouldn't be a major national health crisis. Nor would lung cancer, "Syndrome X" diseases, etc.. And we have Big Pharma, catering to the public's lack of responsibility and providing a pill for everything under the sun, without any thought of treating the cause rather than just the symptoms. Why should they? They're making tons of money on those drugs. When I look around at all the obese people (of their own bad health choices, most of them), heavy smokers, couch potatoes, et al, I ask myself- why should I subsidize, with my tax dollars, the bad health habits of these irresponsible idiots?

@Db - So am I to assume that you've made every right choice, never went 1 calorie over your standard daily intake, never shared a room with anyone who might have smoked and walk or ride a bike where-ever you go?

I lived with a smoking family for 26 years before the last one, my father, gave up smoking because of work. He's had at least two heart attacks and has been doing a damn good job of keeping my stress levels up.

My luck with my weight has not been great, but it's something that I've been working to try to keep under control.

I admit that I'm not the healthiest person in the world, but I try. I shouldn't be denied care because some self important jackass thinks s/he is more important then any other living being on this world. Guess what, you AREN'T.

If we spent money to educate people on how to live a more healthy lifestyle, or hell, even to have a doctor scream at some people to EXERCISE on a regular basis, then maybe we would be better off. But you know what? Every person with an attitude of 'I don't want to cover people who might not have lived the most healthy of lifestyles' doesn't make things better. In fact, that kind of lifestyle isn't very healthy at all, it leads to people going 'I deserve this cake, I've worked hard', or 'I don't need to exercise today, I've worked hard'. Holier then thou attitudes are part of the reason we as a people have so many damn problems in the first place.

I think I love Annie.When I worked at a psych hospital, one of my colleagues asked an insurance reviewer for his full name and address so we'd know who to put down on the police report when the patient left and blew his brains out after his insurance company refused to pay for him to be admitted. The admission was then approved.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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